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Treating Hallux Abductor Valgus Conservatively Through Foot Mobilisation Techniques

A Case Study

Patients presenting with hallux abductor valgus (HAV) are common in podiatry practices. There is a lack, however, of good quality studies on conservative treatments for HAV. 1 This paper describes a case where a patient sought treatment for a painful HAV and requested non-surgical treatment as a preference. This patient was treated using a manual therapy approach of foot mobilisation techniques (FMT) and specific foot exercises. This treatment option was selected to address the articular and periarticular adhesions, which has been one of the objectives of manipulative therapies in humans. 2,3 While this form of treatment has been used extensively for ankle sprains4,5 there is little evidence reported in the literature of the use of manual therapies for HAV. 1 The primary aims of the treatment were: 1. To improve the quality of motion (QOM) and range of motion (ROM) of affected joints. 2. To stretch contracted connective tissues. 3. To strengthen weakened muscles. The treatment interventions used were: 1. Joint mobilisations and manipulations. 2. Isometric strengthening exercises. The treatment plan was conducted over a six-month period. Clinical and radiological findings are presented. The effect of combining two types of interventions must be borne in mind when considering the results, and this limitation is acknowledged in this case study.

Clinical Observations

The patient was an active Caucasian female aged 53 years and in good general health. The patient participated regularly in tennis and bushwalking. The chief complaint of a painful and inflamed 1st metatarsophalangeal joint (MTPJ) had a gradual onset over three years but with increased discomfort during activity over the 6 months prior to seeking treatment. The symptoms were reported as:

1. Consistent ache on the plantar aspect of the 1st MTPJ (L>R). This was reproduced with compression of the medial sesamoid in a dorsal and lateral direction. This was suggestive of a laterally subluxed medial sesamoid with a medially displaced 1st metatarsal.

2. Acute pain along the medial eminence of the left 1st MTPJ during physical activity. It was becoming increasingly more difficult to accommodate the enlarging joints in regular footwear. No relevant medical or traumatic history was noted. A positive family history of HAV was reported with unsuccessful surgical treatment results.

The Foot Health Status Questionnaire6 (FHSQ) recorded 50/100 for ‘Foot Pain’ and 72/100 for ‘Foot Function’. Clinical biomechanical observations noted were:

● Moderately over-pronated resting stance position of the subtalar joint (STJ) and mid-tarsal joint (MTJ) on both feet.

● HAV classified on radiographs as between Stages 2 and 3 (L) using the Root et al classification method. 7

● Limited joint motion of the STJ & MTJ in the supinatory direction.

● Limited joint motion of the 1st MTPJs in the direction of dorsiflexion and adduction.

● Moderately poor QOM of both 1st MTPJs characterised by moderate crepitus with movement.

● The ‘concertina test’ described by Wilson, where pressure is applied to the hallux to create an increased inter-metatarsal angle in the transverse plane, was negative. 8

Diagnostic Tests

Weightbearing plain radiographs were ordered and taken in the normal angle of gait. Radiographic measurements were ruled using the standard guidelines. 9,10

The measurements were consistent with STJ over-pronation with metatarsus primus varus and hallux abductus on the left. No valgus hallux rotation was detected. See Table 1.



Rationale for treatment

Woo et al demonstrated in animal studies that joint hypomobility resulted from collagen cross-linkages that occur in response to immobilisation or disuse. 11

Human studies and recent understandings of connective tissue response to immobilisation or disuse have provided bases for physical therapy treatments of joint hypomobility. 12

In this case, the relationship of the articular surfaces of the 1st MTPJ (L) were consistent with Piggott’s categorisation of the joint being ‘subluxed’. 13

A joint that is subluxed either permanently or functionally has an altered ROM, which leads to a relative disuse and connective tissue atrophy. This case presented with connective tissue adaptation around the STJ, MTJ and the 1st MTPJs, where it had adapted to its shortest functional length. It was the author’s opinion that the presenting symptoms resulted from specific connective tissue adaptations located over the dorso-lateral aspect of the STJ and MTJ and along the lateral border of the 1st MTPJ.

The hypothesis was that the subluxation pattern of the 1st ray was contributing to a lateral subluxation of the medial sesamoid, the primary symptomatic site, leading to a strain in the sesamoid ligament and excessive pressure on the inter-sesamoid crest of the 1st metatarsal head.

The treatment plan objective was to improve joint ROM of the hypomobile joints identified through specific joint mobilisation and manipulation.

The mobilisations were specifically selected so as to apply an exact amount and direction of force to breakdown the connective tissue adaptations noted.

It was hypothesised that, if done repetitively, the collagen cross-linkages could be made to resorb and the connective tissues would re-model to yield an improved functioning joint position and enhanced ROM.

It was also the author’s opinion that the patient would gain long-term benefit through specific exercises to restore optimum muscle function to maintain joint ROM improvements achieved.

Treatment

The FMT protocol used at each treatment consisted of the following techniques (Figures1-6).

The joint mobilisations were provided at a frequency of three times per week for a three-month period. This time period was selected to match the time required for the cellular turnover rate of joint connective tissues. 14



Exercises

Foot muscle exercises were selected on physiotherapeutic principles of strengthening and re-training the affected muscles to stabilise the tarsal and metatarsal bones of the feet (Figures 7–11). 15,16




Radiographic measurements results

X-rays were repeated by the same radiographer after three months and six months of treatment (see Figures 12 and 13). The measurement data are presented in Table 2.






Outcome measurement results

The FHSQ was used to gather an empirical measurement of the patient’s subjective experience as it has positive reliability and validity ranking. 6

The FHSQ results showed an improvement in both foot pain and foot function measurements at three and six months (see Table 3).




Discussion

This case demonstrated joint movement limitations resulting from connective tissue adaptations affecting certain joints of the feet.

The treatment rationale used in this case is based on implementing manual therapies to break down the connective tissue cross-linkages to restore joint mobility and joint alignments. This is the biomechanical basis for joint mobilisation and manipulation used in chiropractic3 and physiotherapy. 17

While there is little published material on the use of these manual therapies in podiatry to achieve changes in joint mobility and alignment, studies by Dananberg, Lawrence, Brantingham and Nield offer evidence to support the use of manual therapies in treating hypomobile related conditions of the foot. 18-22 Ferrari states that there is insufficient evidence on which to select effective conservative treatments for HAV deformity. 1

This case study suggests that research into the use of manual therapies is warranted in order to provide practitioners and patients with an alternative conservative treatment option for HAV deformity.


References

1. Ferrari J, The assessment and conservative treatment of hallux valgus deformity in healthy adults. British Journal of Podiatry 2006; 9(4): 104-108.

2. Evans D, Mechanisms & effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. J Manipulative Physiol Ther 2002; 25(4): 251-262.

3. Lantz, C A, A critical look at the subluxation hypothesis. J Manipulative Physiol Ther 1989; 12(2): 152-155.

4. Green T, Refshauge K, Crosbie J, Adams R, A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy Journal 2001. physicaltherapyjournal.org/cgi/ content/abstract/81/4/984

5. van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA, Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy 2006; 52: 27-37.

6. Bennett P, Patterson C, Wearing S, Baglioni T, Development and validation of a questionnaire designed to measure foothealth status. Journal of the American Podiatric Medical Association 1998; 88(9): 419-428.

7. Root M, Orien W, Weed J, Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol II. Los Angeles: Clinical Biomechanics Corporation 1977: 398-412.

8. Wilson D, Hallux valgus and rigidus. In Helal B, Wilson D (Eds), The Foot, Vol 1. Churchill-Livingston 1988: 411-483.

9. Gamble F, Yale I, Clinical Foot Roentgenology, Edn 2. Krieger Pub, Huntington NY 1975: 199.

10.Christman R, Foot and Ankle Radiology, Churchill Livingston 2003: 275.

11.Woo S, Matthews J, Akeson W, Amiel D, Covery F, Connective tissue response to immobility. Correlative study of biomechanical and biochemical measurements of normal and immobilized rabbit knees. Arth Rheum 1975; 18: 257

12.Culav E, Clark H, Merrilees M, Connective tissues: matrix composition and its relevance to physical therapy Phys Ther 1999; 79(3): 308-319.

13.Piggott H, The natural history of hallux valgus in adolescence and early adult life. J Bone Joint Surg 1960; 42B: 749-760.

14.Yi Jun Yang, MD, PhD, In: eMedicine Specialties Histology of Bone. Last Updated: August 19, 2002.

15.Mahoney A, Foot Strengthening Exercises. Self Published 2005: pp 3, 10, 32.

16.Bahram J, MPhty (Manip), BSc, Evaluation and retraining of the intrinsic foot muscles for pain syndromes related to abnormal control of pronation, Clinical Articles. Advanced Physical Therapy Ed. Institute, Ontario, Canada.

17.Maitland, GD. Peripheral Manipulation. 3rd Edn. London: Butterworth-Heinemann 1991: 53-61.

18.Dananberg HJ. Manipulation method for the treatment of ankle equinus. Journal of the American Podiatric Medical Association 2000; 90(8): 385-389.

19.Lawrence DJ. Pes planus: a review of etiology, diagnosis and chiropractic management. J Manipulative Physiol Ther, 1983; 6: 185-188.

20.Brantingham JW, et al. Inter-examiner reliability of palpation for foot and ankle joint tenderness: a pilot study. JNMS 1995; 3: 188-191.

21.Brantingham JW, et al, Inter-examiner reliability of the circumduction test for general foot mobility/joint dysfunction. Journal of the American Chiropractic Association, June 2003.

22. Nield S, et al, The effect of manipulation on range of movement at the ankle joint. Scand J Rehabil Med, 1993; 25: 161-166.

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